Anesthesia Coding Alert

Question: A patient underwent CABG one day, and it was reopened the next. The same anesthesiologist was present during both procedures. He did not indicate use of the pump oxygenator on the second day, but did document hypothermia and hypotension. Is this medically possible? Some of the anesthesia codes seem to fit in some ways, but not others. For example, 00562 is for re-operation for CABG, but should be more than one month after the original operation. How should we code the second surgery?

Wisconsin Subscriber

Answer: Although you don’t indicate it in your question, chances are good that a complication occurred (such as postoperative bleeding). The anesthesia code will depend on whether the second procedure involved the heart, pericardial sac, or great vessels of the chest (00561 as pump oxygenator wasn’t indicated) or direct bypass grafting (00566 as pump oxygenator wasn’t indicated). Both of these code selections include utilization of hypothermia (+99116, Anesthesia complicated by utilization of total body hypothermia [List separately in addition to code for primary anesthesia procedure]) and hypotension (+99135, Anesthesia complicated by utilization of controlled hypotension [List separately in addition to code for primary anesthesia procedure]) and they will not be reported separately. The assigned diagnosis will depend on the reason for the return to the OR, for example post operative bleeding.

Check with the anesthesiologist who provided the services to ensure the information is correct prior to submitting the claim.